Healthy Skepticism International News

May 2002

Antibacterial advertising: Encouraging healthy scepticism among doctors.

May 2002 Vol 20 No 5
By Peter Mansfield and Melissa Raven
Key words: pharmaceutical advertising, antibacterials, scepticism

Peter R. Mansfield BMBS is a general practitioner and Director of Healthy Skepticism, previously MaLAM (Medical Lobby for Appropriate Marketing). .(JavaScript must be enabled to view this email address)

Melissa Raven BA(Hons), MPsych(Clin), GradCertHealthEc, GradCertPharmacoec, GradCertTertEd is a lecturer and Coordinator, Drugs & Public Health (previously Addiction Studies) in the Department of Public Health, Flinders University, South Australia. .(JavaScript must be enabled to view this email address)

Abstract

Antibacterials are among the most commonly advertised pharmaceuticals, despite concern about their excessive and inappropriate use. The February 1999 edition of Healthy Scepticism New Zealand critically appraised five antibacterial advertisements published in NZ Doctor or NZ GP in 1998. It was sent to all New Zealand GPs and trainees, who were given the opportunity to comment on each advertisement regardless of their assessment of the antibacterials themselves, on their intentions to change their prescribing, and on their satisfaction with Healthy Scepticism. 136 doctors responded. All five advertisements were judged by most respondents to be at least somewhat inappropriate, and many critical comments were made. A majority of respondents reported some intention to change their prescribing of antibacterials, and most reported being very satisfied or relatively satisfied with the edition of Healthy Scepticism. The evaluation confirms the value of Healthy Scepticism as an educational strategy to assist at least some doctors to critically appraise pharmaceutical advertising but the views of the majority of doctors who did not respond remain unknown.

Introduction

Inappropriate use of antibacterials has been identified as a serious medical issue. Resistance to antibacterials is now emerging at a faster rate than replacement antibacterials can be developed.[1] Resistance imposes substantial economic costs on society, as do adverse reactions and the actual cost of the drugs.[2] However, antibacterials are among the most commonly advertised pharmaceuticals, and there is empirical evidence that doctors’ prescribing patterns are influenced by pharmaceutical advertising.[3][4][5]

Healthy Scepticism New Zealand (HSNZ) was a newsletter produced by MaLAM (Medical Lobby for Appropriate Marketing, now known as Healthy Skepticism), which aims to defend health care from misleading and harmful marketing.. HSNZ was funded by PHARMAC and sent to all New Zealand general practitioners and trainees in any speciality on the mailing list of Atlantis (formerly Datamagic). The February 1999 edition (the third edition) of HSNZ focused on advertising of antibacterials.

Method

Five antibacterial advertisements published in NZ Doctor or NZ GP in 1998 were analysed in HSNZ. The drugs advertised were Augmentin (SKB), Ceclor (Lilly), Diclocil (BMS), Helicosec (Astra), and Noroxin (MSD). For each advertisement, the headline, key copy, and visual image were described. Then the appeals (e.g. sympathy) were analysed, possible alternative interpretations of the promotional claims were listed, and the quality of evidence supporting use of the antibacterial for the promoted indications was analysed. For all advertisements, it was argued that most or all of the interpretations were unjustified on the basis of scientific evidence.

The newsletter was sent to 4806 doctors. An anonymous feedback form was included, seeking qualitative and quantitative responses. Doctors were asked to rate each advertisement regardless of their assessment of the antibacterial itself. A seven-point Likert scale was used, anchored with ‘Inappropriate’ and ‘Appropriate’. Doctors were also asked how they felt about that edition of HSNZ, and whether, after reading it, they intended to change their prescribing.

136 feedback forms were returned and four letters were received. The quantitative data were entered into a Microsoft Access 2000 database. Medians were calculated with Stata 6 statistical software. The response rate was 3%. Although this is low, it needs to be viewed in the context that general practitioners receive as many as 5100 pages of unsolicited written material[6] and 24 requests to participate in research each year.[7] Furthermore, no reply paid envelope was included, nor was there a fax-back option because there was no funding for evaluation. No demographic data were requested, so nothing is known about the respondents other than the fact that they were on the mailing list. Consequently, the views of the respondents cannot be generalized to the 97% of doctors who did not take up the opportunity to respond. However, every single doctor’s views are important for the patients who depend upon them, so the views of 136 doctors deserve consideration.

Results

Feedback about the individual advertisements is discussed first, followed by reported intentions to change antibacterial prescribing, then more general comments about pharmaceutical advertising, and finally feedback about HSNZ.

Individual advertisements

Augmentin (amoxycillin/clavulanate)

A majority of respondents reported that they felt SKB’s advertisement for Augmentin was inappropriate (1 or 2 on the 7-point scale; median = 2).

Figure 1. Appropriateness of Augmentin advertisement

I feel that SKB’s advertisement for Augmentin (amoxicillin/clavulinate) is:
1 = Inappropriate, 7 = Appropriate, U = Unspecified
N = 125

Most comments about the advertisement were critical. A major theme was the inappropriate promotion of relatively indiscriminate use of Augmentin:

• It is pushed as the “for any infection” drug.

• I see many GPs using Augmentin as a 1st line drug in older children for viral infections. This ad encourages use (without thought) for just about anything.

The lack of clinical information was noted, and the advertisement was described as insulting:

• As with all of these ads, I think they are fairly insulting to GPs. What other professionals have such childish images put forward to them?

Ceclor (cefaclor)

A majority of respondents categorised Lilly’s advertisement for Ceclor as inappropriate or relatively inappropriate (1 or 2 on the 7-point scale; median = 2).

Figure 2. Appropriateness of Ceclor advertisement

I feel that Lilly’s advertisement for Ceclor (cefaclor) is:
1 = Inappropriate, 7 = Appropriate, U = Unspecified
N = 123

Again most comments about the advertisement were critical:

• Very naughty advertising – does it contravene the consumer protection act?

• They encourage misuse of a drug with this ad.

• Ad supports a very common misconception. In practice it would be very difficult to distinguish viral/bacterial clinically.

However, one respondent expressed the view that doctors would not be misled:

• Use of images misleading but docs are clever enough to work it out!

Diclocil (dicloxacillin)

A majority of respondents categorised BMS’s advertisement for Diclocil as inappropriate, relatively inappropriate, or somewhat inappropriate (1, 2 or 3 on the 7-point scale; median = 3).

Figure 3. Appropriateness of Diclocil advertisement

I feel that BMS’s advertisement for Diclocil (dicloxacillin) is:
1 = Inappropriate, 7 = Appropriate, U = Unspecified
N = 121

Again most comments were critical. Two respondents commented on the inaccurate representation of how often Diclocil is appropriate:

• Misleading: suggesting that staph. is the prime cause of wound infections.

• This drug is needed in a small percent of cases and this advert misses that fact.

Two focused on the methodological quality of the evidence cited in the advertisement.

• Use of relative risk is very deceptive.

• Usual story: crappy data inflated to the status of a major study.

Another reported being susceptible to the impact of the advertisement:

• I don’t know much about Tx wound infection or Diclocil. This ad would have made me think about using this. Healthy Scepticism is good for educating me.

However, there were two comments that were more positive about the advertisement:

• Think you’ve been harsh on this ad.

• BMS have some evidence to suggest Diclocil is a better drug than flucloxacillin so have based their argument accordingly. However, non-specific claims have been made which cloud the issues.

Helicosec (omeprazole, amoxycillin, metronidazole)

A majority of respondents described Astra’s advertisement for Helicosec as inappropriate, relatively inappropriate, or somewhat inappropriate (1, 2 or 3 on the 7-point scale; median = 3).

Figure 4. Appropriateness of Helicosec advertisement

I feel that Astra’s advertisement for Helicosec (omeprazole, amoxicillin, metronidazole) is:
1 = Inappropriate, 7 = Appropriate, U = Unspecified
N = 119

Some comments were critical, but less so than for the other advertisements:

• Inappropriate to promote eradication of all H. pylori.

• Some useful info but misleading with claims.

There were two positive comments:

• Advertising has a reasonable “evidence” base.

• I think this is a reasonable ad.

Noroxin (norfloxacillin)

A majority of respondents categorised MSD’s advertisement for Noroxin as inappropriate or relatively inappropriate (1 or 2 on the 7-point scale; median = 2).

Figure 5. Appropriateness of Noroxin advertisement

I feel that MSD’s advertisement for Noroxin (norfloxacin) is:
1 = Inappropriate, 7 = Appropriate, U = Unspecified
N = 120

Comments about this advertisement were particularly critical. A major theme was the emotional manipulation:

• This one really pisses me off. The idea that I’m a cruel doctor if I risk severe pain for my patient if I don’t prescribe norfloxacin I find deeply offensive.

• I was aware of the overdramatic presentation. I wondered if it implied she had pyelonephritis! This in itself is misleading.

• I agree – I can’t remember any patient “doubled up” like this with cystitis.

• I totally agree – not first line therapy and over the top emotional content.

The data presented in the advertisement were described as ‘shockingly poor’. One respondent focused on the risk of resistance to the drug:

• No thought given to emergence of resistance to norfloxacin. Unfortunately, ad. reinforces belief of many local GPs.

Intentions to change antibacterial prescribing

A majority of respondents reported some intention to change their prescribing of antibacterials after reading HSNZ (score 5, 6 or 7; median = 5).

Figure 6. Intention to change prescribing

As a result of reading this edition of Healthy Scepticism I intend to change my prescribing:
1 = Not at all, 7 = Significantly, U = Unspecified
N = 125

Others indicated that that they did not intend to change their prescribing significantly because HSNZ reinforced what they believed they were already doing.

• I largely follow these recommendations already.

• I don’t mean to boast but it tends to conform with what I already try to do.

Some indicated that it reinforced a change that they had recently made, for example in response to education from their Independent Practitioners Association:

• But this is because our IPA peer GP meetings have looked at these issues recently. Otherwise I might be more affected by your paper.

Several commented on the usefulness of HSNZ in relation to antibacterial prescribing:

• Thought provoking. Good to review optimal Rx options, e.g. Helicobacter ulcers. This is the most useful aspect for me in helping change my prescribing habits.

• Antibiotics are difficult. Firstly trying to not prescribe them, which I am strong on, and secondly choosing the correct one to treat the problem appropriately while not increasing resistance. This article helped.

Some respondents reported planning to review/revise their prescribing practices in relation to specific drugs:

• I’ve used this drug [Ceclor] extensively as first line especially for children, and I’ll review this.

• I’ve been using it [Noroxin] as first line. I will revise that and use trimethoprim.

Pharmaceutical advertising in general

A range of comments were made about pharmaceutical advertising in general. One of the main issues discussed was whether or not doctors are influenced by promotion. A few respondents were adamant that doctors were immune to pharmaceutical advertising or that they themselves were not influenced:

• Obvious – doctors are not idiots.

• Not read. GPs are not stupid as you infer.

• Who reads the ads anyway?…Drs in general very sceptical about colour ads!

• I’m not influenced by the advertising. It washes over me like water off a duck’s back.

Others thought that doctors were in fact susceptible:

• I agree doctors are very swayed by drug company reporting. I am particularly concerned about our use of antibiotics for obvious viral infections.

• I suspect we have no idea of how this subliminal stuff affects our prescribing!

One respondent commented on the risk of complacency:

• I think I don’t overuse ab’s – trouble is we probably all think that!

There were also comments on the presentation and quality of information provided by drug companies in other contexts:

• You may not have noticed if you check your New Ethicals Compendium that the drug information it contains mostly use the trade name when referring to positive effects and the generic name when referring to side-effects – scepticism is important – very clever marketing.

• Good to have all the issues exposed. Drug companies need to be more accountable in their drug advertisements and in the information presented when reps call. Not all that information is accurate.

Satisfaction with Healthy Scepticism New Zealand

A large majority of respondents reported that they were relatively satisfied or very satisfied (6 or 7 on the 7-point scale; median = 6) with this edition of HSNZ.

Figure 7. Satisfaction with Healthy Scepticism New Zealand

Regarding this edition of Healthy Scepticism, I am:
1 = Very dissatisfied, 7 = Very satisfied, U = unspecified
N = 131

Furthermore, four of the five respondents who did not give a score for their satisfaction made positive comments:

• Please don’t give up this publication!! Doctors need it even if they don’t admit it!

• I find it excellent in making me think about what I read & how this influences my prescribing.

• Generally excellent publication. I hope you can continue.

• Good to consider the pressures on prescribers that we often overlook.

However, a few respondents were very critical of HSNZ, MaLAM and/or PHARMAC:

• I think there is a reasonable point being made about overuse of antibiotics – but it is being made in all the other magazines. I find the interpretations (possible) of ads patronizing and a waste of paper – who reads the ads anyway? A waste of time. Drs in general very sceptical about colour ads! Sometimes too sceptical (as I may seem in these answers.)

• Cannot see a reason for your organisation….GPs are not stupid as you infer.

• I feel it is far too negative. I am concerned Pharmac’s agenda is purely cost cutting.

• I cannot approve Healthy Scepticism because it’s funded by PHARMAC. Even if no bias intended – it’s going to be impossible to separate CONFLICT OF INTERESTS.

Others expressed some ambivalence or constructive criticism:

• It is always good to read the other side! I feel both are extremes though. Maybe your article being over critical and drug companies being under critical. Is the truth not somewhere in between. Doesn’t help to quote a few pertinent lines out of selected articles.

• Content is biased, but unashamedly so. A more balanced viewpoint might give more credibility.

• Perhaps slightly negative. After all I do need to use some drugs which are advertised. Overall: informative and useful.

• Keep up the good work but don’t get too evangelical.

Some alternative and/or complementary strategies were suggested:

• I wonder if you might be better to start “counter advertising” – ads which clearly and succinctly state what you are saying in Healthy Scepticism.

• Would be nice if PreMeC or Pharmac could produce PreMeC type prescriber info, eg â€˜choice of antibiotic / no antibiotic in common conditions’, or â€˜strategies for reducing antibiotic resistance’ as backup for the MaLAM topics.

Several themes emerged in the many positive comments. Firstly, general enthusiasm for HSNZ and endorsement of its usefulness was expressed:

• A lot of useful information + arguments to help put the issues in perspective.

• Excellent viewpoints + analysis.

• Easy tool to improve habits and confirm good judgement.

The brevity of HSNZ was endorsed by several respondents:

• Short, simple, to the point and well researched.

• Aims @ right level & is right length for those engaged in the paper war.

There were comments about the value of HSNZ specifically as a counter to pharmaceutical promotion:

• It is nice to have my own scepticism about antibiotics and drug company ploys reinforced.

• It is so helpful to have the balancing opinion to weigh against the advertising. Thank you.

• Thank you. It certainly makes one look at the prescribing, which becomes a habit with certain drugs, probably driven initially by advertising. I’d be sorry to see it [HSNZ] lapse.

Many respondents expressed the hope that HSNZ would continue:

• Keep them coming. I don’t read many ads, but appreciate your investigation into their claims.

• All issues have been a very interesting and a welcome addition to my â€˜in tray’. Further issues would be read & appreciated.

• Would strongly support continuation of this excellent publication.

• This is great!!! We need more!

Discussion

All five advertisements were considered by most respondents to be at least somewhat inappropriate. Major themes included promotion of indiscriminate use, poor data quality and methodological issues, emotional manipulation, and the fact that advertisements insulted doctors’ intelligence.

A majority of respondents reported some intention to change their prescribing of antibacterials as a result of reading the edition. Whether or not such intentions lead to sustained behaviour change would require further investigation. However, there is some evidence that when doctors state an intention to change prescribing practices, an actual change results 50% of the time.[8]

Respondents reported finding reading the HSNZ edition a useful strategy for increasing their awareness of potential problems associated with antibacterial advertising. Overall, there was very strong support for HSNZ from respondents. The issue of lack of independence from PHARMAC, raised by a small number of respondents, has been discussed in a subsequent edition of HSNZ.[9] In response to the objections about lack of independence, MaLAM attempted to find alternative funding for HSNZ but was unsuccessful.

Many doctors are aware that they are potentially influenced by pharmaceutical advertising, but may not have the skills to recognise and critique problematic advertisements. The results of this evaluation suggest that many respondents enthusiastically welcome and benefit from education about how to critically appraise advertisements. The results also confirm the acceptability and usefulness of HSNZ as a medium to provide such education for most respondents. Further study would be required to determine the views of non-respondents.

Acknowledgements

Thanks to PHARMAC for funding the production and distribution of Healthy Scepticism NZ, to PreMeC for providing feedback on drafts of the edition, to the New Zealand Family Physician for comments on this report and especially to the GPs and trainees who took the time to provide feedback.